ML20059M824
| ML20059M824 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/17/1993 |
| From: | AFFILIATION NOT ASSIGNED |
| To: | |
| References | |
| OLA-2-I-MFP-025, OLA-2-I-MFP-25, NUDOCS 9311190359 | |
| Download: ML20059M824 (13) | |
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- QI(]f'EK DC493-HP-N029 Rev. 0 1
' July 27,1993
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MANAGEMENT
SUMMARY
l Four identified instances of personnel entering areas posted as high radiation areas :(HRAs) occurred without the required' l continuous monitoring or alarming dosimetry.
Subsequent surveys by radiation protection determined that personnel had not been exposed to dose rates greater than 100 mR/hr.
For the events.the root cause.was personnel ertar -
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inattention to detail in that workers were inattentive to Radiation Protection's " posted" HRA boundaries.
Contributing to this, for one event was the failure of an RP technician to issue alarming dosimeters to the workers, i
The corrective actions include:
(1) Issue a letter from Plant Management to all employees explaining the-importance of postings in the plant and adherence to good radiological work practices.
The letter will also outline disciplinary actions for these occurrences; (2) RWP and SWP coversheets
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will be revised to provide clearer guidance for HRA entries; (3) Appropriate RP procedures will be revised to limit the use of "stop" signs for HRA posting only.
In addition, the wording that, " conditions have changed," will be deleted and
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j irif orw.at. ion on requirements f or' entry into HRAs Vill be -
added; and (4) General employee training will be revised to-j include information on the corrective measures from the TRG, l
l including a requirement for discipline for personnel who inadvertently enter a HRA.
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The next TRG is scheduled for May 26, 1993, at 10:00am.
The TRG will discuss the corrective actions and the NCR write-up.
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4 NCR DC493-HP-N029 Rev. O JuN 27,1993 NCR DCO-93-HP-N029 HIGH RADIATION AREA ENTRY I.
Plant Conditions Plant conditions are not applicable to this event.
II.
Description of Event A.
Summary:
B.
Background:
C.
Event:
l For identified instances of personnel entering
" posted" High Radiation Areas (HRAs) occurred without the required continuous monitoring dosimetry.
These postings serve as a warning for personnel in order to ensure that personnel are aware of radiological conditions inside the
" posted" boundary.
Subsequent surveys by radiation protection determined that personnel had not been exposed to dose rates greater than 100 mR/hr. In all cases,.
the workers were removed from the area.
They were also counseled by RP supervision about the requirements of entering a HRA.
In all cases, detailed surveys were done to verify the dose rates in the area.
At no time did any worker enter an actual HRA.
D.
Inoperable Structures, Componerts, or Systems.that Contributed to the Event:
None.
E.
Dates and Approximate Times for Major Occurrences.
1.
October 2, 1992:
In Service Inspection worker was observed near the Refueling Bridge, 140' elevation, without an alarming dosimeter. (ref.
2).
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- NCR DC493-HP NO29 Rev. O July 27,1993
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l 2.
October 26, 1992:
Scaffold workers were observed crossing HRA boundaries on the 140' elevation, behind the
'CFCU, without an alarming dosimeter (ref. 3).
3.
March 15, 1993:
Workers entered a HRA by lifting a grating on the 115' elevation, and upon discovery, were issued alarming dosimeters in order to-complete the task and leave the job site in a safe condition (ref. 4).
4.
March 22, 1993:
Worker was. observed in the 160' elevation pressurtzer l
shed without an alarming I
dosimeter (ref. 5).
t F.
Other Systems or Secondary Functions Affected:
None.
G.
Method of Discovery:
- Utility personnel, during the performance of various scheduled (or unscheduled) activities, identified three of the HRA entries; while one was identified by contract workers.
H.
Operators Actions:
sm sa.
o None.
I.
Safety System Responses:
None.
III.
Cause of the Event A.
Immediate Cause:
Workers violated physical boundaries and entered a posted HRA without proper dosimetry.
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NCR DC493-HP-N029 Rev 0 July 27.1993 B.
Determination of Cause:
1.
Human Factors:
a.
Communications:
Regarding event #4 above, there was a communications breakdown-between the workers and the RP technician resulting in a failure to issue a?. arming dosimetry.
This contributed to the occurrence, even.
though personnel _are trained not to enter posted HRAs without meeting.the TS requirements.
I b.
Procedures:
Radiation Control Standard RCS-4 does provide guidance for HRA postings.
c.
Training:
Though personnel knew the requirements for HRA entry,. additional emphasis may be required.
d.
Human Factors:
1.
Postings which contain the insert "High Radiation Area" are similar tc postings used by the entire industry.
However, as a matter of policy, RP also uses "Stop" signs.
These signs, shaped like the traffic sign, are large " day glow pink" signs which state " Step. Radiological conditions have changed. Read and comply with postings before entering this area'."
In addition to this, the insert for the regular posting, which states, "High Radiation Area," is also " day glow pink."
2.
Personnel do not always take time to read and take note'of the postings or changes to them.
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. l NCR DCD 93-HP-N029 Rev, b July 27,1993 3.
Personnel.that havel violated High Radiation Area signs have stated-that they' knew the-requirements.
e.
Management System:
Even with the best training,.' signs, and' procedures,-safe radiological practices may^not be1 fallowed without1 supervisory; and management.att2ntion at-all levels.
2.
Equipment / Material:
a.
Material Degradation:
N/A-
-2 b.
Design:
Human factors - design.of.the signs may.be a factor.-
c.
Installation:
Human factors - placement'ofJsigns may be
' a factor, d.
Manufacturing:
N/A~
e.
Preventive Maintenance:
- N/A
^
f.
Testing:
N/A.
g.
End-of-life failure:
- N/A
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C.
Root Cause:
- t 1.
For all events.
Personnel error - inattention to detail.in that workers 'were inattentive to: Radiation '
Protection's posted.High Radiation' Area (HRA) boundaries.
In all cases, the-. individuals'could' state the procedural requirements'for entry.:into a HRA,-
however they'did not make the connection-
-between the procedural' requirements"and theirL specific situation.
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NCR DC493-HP-N029 Rev. O JuN 77, t993 D.
Contributory Cause:
1.
For events #1, #2, #3:
Workers do not always. read and take note of postings or changes to them.
Radiological conditions during an outage may change in the RCA due to new plant system alignments and radiography.
Due to these changes, existing postings may change from Radiation Areas to HRA.
2.
For event #4:
Contributory causes for this event were poor
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communication between the workers and the RP technician, and personnel error by the RP technician.
The RP technician forgot to issue the alarming dosimeters even though he had issued them earlier in the day to the same individuals working in the same area.
- Also, the workers failed to ask for alarming dosimeters while being briefed by the RP technician.
IV.
Analysis of the Event A.
Safety Analysis:
- This nonconformance deals with violations of administrative Technical Specification 6.12.1, which restricts entry into High Radiation Areas.
At no time did any worker enter an actual HRA (area where dose rate is greater than 100mR/hr).
These areas are not accessible to the genera:
public.
Therefore, the health and safety of the public has not been adversely affected by these events.
B.
Reportability:
1.
Reviewed under QAP-15.B and determined to be' non-conforming in accordance with Section 2.1.3 as an event requiring resolution through the nonconformance process.
2.
Reviewed under 10 CFR 50.72 and 10 CFR 50.73 per NUREG 1022 and determined to be not reportable, since the root cause does not appear to be a programmatic deficiency -
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NCR DCOL93-MP-N029 Rev,0 Ju;y 27.1993 i
signs were posted, personnel h'ad been: trained on the' requirements, and personnel were familiar with the requirements..
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3.
This problem does not require a'10 CFR;21 report.
4.
This problem does not require reporting via zul INPO Nuclear Network entry.
5.
Reviewed under 10-CFR-'50.9 andLdetermined to be not reportable since this event does not have a significant; implication for public health-and: safety or' common defense and j
security.
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V.
Corrective Actions A.
Immediate Corrective Actions:
1.
For event #4, the RP. technician:was counselled on the incident-(ref. 5).
In addition, thel issue was discussed at.RP section meetings and turnovers.
2.
In all cases, the workers were removed from i
the area. -They~were alsofcounseled by RP' c
supervision about the' requirements;of entering-
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a HRA.
l 3.
In all cases, detailed' surveys were done to verify the dose: rates'in the area.
At'no time did any worker enter an actual HRA.
-v
-m B.
Investigative Actions:
None.
1 C.
Corrective Actions to Prevent Recurrence:
.1.
Issue a letter'from Plant Nbnagement to all' employees explaining:.the importance.of-1 postings in the plant;and adherence to good'.
radiological work practices. LThe letter will also require and provide guidance forL appropriate disciplinary actions for these occurrences.
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NCR DC093-HP-N029 Rev,0 -
July 27,1993 RESPONSIBILITY:
R. Gray ECD:
9/01/93 DEPARTMENT:
Radiation Protection Tracking AR:
A0307248, AE #04 Outage Related? No OE Related?
No l
NRC Commitment? Yes CMD Commitment? No STATUS: Assigned 2.
Revise RWP and SWP coversheets to highlight information on high radiation area controls.
RESPONSIBILITY:
R. Gray ECD:
12/31/93
)
DEPARTMENT:
Radiation Protection Tracking AR:
A0307248,'AE #05 Outage Related? No OE Related?
No l
NRC Conmitment? Yes CMD Commitment? No STATUS: Assigned 3.
Revise appropriate RP procedure (s)'to limit the use of "stop signs" for posting only High Radiation Areas.
In addition, the wording that " conditions have changes," will be deleted and information on requirements for entry into High Radiation Areas will be added.
RESPONSIBILITY:
R. Gray ECD:
12/31/93 DEPARTMENT:
Radiation Trotection Tracking AR:
A0307248, AE #06 Outage Related? No OE Related?
No l
NRC Commitment? Yes CMD Commitment? Yes STATUS: Assigned 4.
General employee training will be revised to include information on the corrective measures from the TRG, particularly, a requirement for discipline for personnel who inadvertently enter a HRA.
RESPONSIBILITY:
A. Dame ECD:
8/01/93 DEPARTMENT:
Access Tracking AR:
A0307248, AE #07 93NCR WP\\93HPN029.KA B kwr PCge 8
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My 27.1993.-
i Outage Related? No OE Related?
No l
NRC Commitment? Yes CMD Commitment? No i
STATUS:. Assigned D.
Prudent Actions:
1.
RP will': evaluate different~ types of barriers for HRAs'.
RESPONSIBILITY: R. Gray.
DEPARTMENT: Radiation Protection TRACKING AR: A0308215, AE #01 ECD: 10/1/93 2.
Discuss with: management the. advantages'of alarming. dosimeter systems, reylacing.
pocket ion chambers (PICS).
RESPONSIBILITY: R.. Gray DEPARTMENT: Radiation Protection' TRACKING AR: A0308215,'AE #02 ECD: 8/1/93 VI.
Additional Informatign.
l A.
Failed Components:
None.
B.
Previous Similar Events:
NCR DCO-87-TC-N107 and LER l'-87-015-00 discuss an event in which a very High Radiation Area.(VHRA) door was left unlocked; however,;the root.cause dealt specifically with VHRA access.- The. previous-event is not applicable to the current NCR, as VHRAs have access requirements that are different from HRAs.
NCR DCO-91-TC-N043 (ref. 6) discusses four events' where the HRA boundaries wereLcrossed due to similar root causes.
These previous events are applicable to the' current'NCR, as personnelferror,;
a lack of attention.to detail, was the root cause:
for the events.
Corrective actions included:~
(1):
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r NCR DC0&HP-N029 Rev, O July 27.1993 Enhancement of Radiation Worker Requalification training specifically emphasizing the.important aspects of the RP program; (2) Issuance of a letter from Plant Management to all employees explaining the importance of adhering to posting in the plant; (3) "Stop" signs; and (4) Revision of RP procedures to provide guidance for when RP-will place-an individual's access to the RCA on hold until the problem has been satisfactorily resolved.
C.
Operating Experience Review:
1.
NPRDS:
Not applicable.
2.
NRC Information Notices, Bulletins, Generic Letters:
A search of'the Operating Experience Assessment database under keywords SIGN and RADIATION revealed the following:
IE Information Notice 84-82. " Guidance for Posting Radiation Areas:"
DCPP's Radiation Control Standard RCS-4. closely follows the guidelines in this Notice.
As the Notice provides only general guidelines against either overposting or inadequate posting, PG&E's inclusion of these guidelines in RCS-4 did not prevent the specific events in the current NCR.
3.
None.
A search of the Operating Experience Assessment database under keywords SIGN.and RADIATION revealed no items.
D.
Trend Code:
Responsible department PG (Plant Staff, General),
and cause code A1 (Personnel Error, Lack of Mental Attention).
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s NCR DCOL93-HP N029 Rev, O July 27. lM3 j
E.
Corrective Action Tracking:
1.
The tracking action request is A0307248, 2.
Are the corrective actions outage related? No.
F.
Footnotes and Special Comments:
None.
G.
References:
1.
NRC Inspection Report 50-275/93-11 and 50-323/93-11 2.
Technical Specification 6.12.1 3.
Action Request (AR) A0279147 4.
5.
6.
AR A0299511 and OE 00010549 7.
NCR DCO-91-TC-N043 l
8.
Tracking AR A0307248 9.
Prudent Action AR A0308215 H.
TRG Meeting Minutes:
i On May 18, 1993, the initial TRG convened and considered the following:
The most recent NCR DCO-91-TC-N043 cited four ARs dealing with unauthorized HRA entries.
The root causes were determined to be:
Personnel error by the RP technician - failure to recognize that the worker would be working in a radiation aream H
surrounded by a high radiation areas; Personnel error - inattention to detail in that workers were inattentive to Radiation Protection's posted HRA boundaries.
In all cases, the individuals could state the procedural requirements for entry into a HRA, however they did not make the connection between the procedural requirements and the specific situation that they were confronted with.
l The past corrective actions from a previous NCR (DC0-91-TC-N043) included: (1) Enhancement of Radiation Worker Requalification training to emphasize (A) how changing plant conditions may affect the location of High Radiation Areas; (B) that when a stop sign is used, workers should'be 93NCRWP93HPN029 KAB awr Page 11 of 13 1
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NCR DC493-HP-N029 Rev, O July 27.1993 especially alert and understand that conditions have changed, and when conditions have changed, they should carefully read the posting; (C) that it is important to stop and read radiation l
protection postings and that some of these postings implement requirements; and -(2) A letter from Plant Management to all employees explaining the importance of postings in the plant and l
adhering to good radiological work practices was issued. (3) Larger, more visible " day-glow" "Stop" signs were to be purchased.
(4) Radiation Protection revised its procedures to provide guidance as to when Radiation Protection will place an individual's access to the RCA on hold until the problem has been satisfactorily resolved.
DCPP and most other nuclear power plants have a TS that was written to provide relief from regulatory requirement of locking an area that has a dose rate of greater than 100mR/hr.
In providing the relief, the TS requires administrative controls.
Once the industry received relief.through the TS, the industry became vulnerable for regulatory problems resulting from human error in implementing the administrative controls.
In all the DCPP cases to date, the personnel' involved did
- not receive a significant dose because multiple controls and barriers were in place to prevent unplanned exposures.
This type of event is very hard to eliminate, however, PG&E is doing its best to realistically achieve the minimum number of occurrences.
There were 163,037 entries into the RCA for 1R5 and 139,313 entries in 2RS.
During the past two-outages (1RS, 2RS), four instances of High Radiation Area (HRA) entries without meeting the Technical Specification (TS) requirements have been identified by PG&E.
The TS requires, in part: RP technician with survey instruments, or an alarming dosimeter and knowledge of radiological conditions in the area.
The root cause of all of these events is personnel error (cognitive) due to inattention to detail.
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0 L i NCR DCS93-HP-N029 Rev. 0 July 27.1993 Subsequent RP surveys proved that none of the personnel, in any of the four instances, were in an actual HRA but were in areas'of dose rates less than 100mR/hr.
The HRA posted boundaries were larger than required, primarily due to ease of boundary location.
l Only one of the ARs has a QE (the event where RP contributed to the incident).
QE's were not created for the other three incidents since different departments and associated QC personnel were involved for each event, and the events were considered isolated incidents, i
Corrective actions regarding the most recent i
occurrences were discussed and will be finalized t
during the next TRG.
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Remarks:
None.
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